Summary

Upper and lower endoscopy is an important tool that is being utilized more frequently by general surgeons. Training in therapeutic endoscopic techniques has become a mandatory requirement for general surgery residency programs in the United States. The Fundamentals of Endoscopic Surgery has been developed to train and assess competency in these advanced techniques. Simulation has been shown to increase the skill and learning curve of trainees in other surgical disciplines. Several types of endoscopy simulators are commercially available; mechanical trainers, animal based, and virtual reality or computer-based simulators all have their benefits and limitations. However they have all been shown to improve trainee's endoscopic skills. Endoscopic simulators will play a critical role as part of a comprehensive curriculum designed to train the next generation of surgeons. We reviewed recent literature related to the various types of endoscopic simulators and their use in an educational curriculum, and discuss the relevant findings.

Introduction

Upper and lower endoscopies have become indispensable aspects of a surgeon׳s skill set. Approximately 18 million endoscopic procedures were performed in the United States by surgeons and gastroenterologists in 2009.1, 2 The average number of endoscopic procedures performed by general surgeons nationwide has doubled from 1999 to 2011.3 In many geographic areas, upper and lower endoscopies are among the most common procedures performed by surgeons,4 however, in rural areas, these are the most common procedures performed.5 The proportion of a general surgeon׳s practice involving endoscopic procedures, in a specific geographic area, was inversely related to the number of gastroenterologists available in that area,2 thus indicating that the surgeons serve a vital role in rural communities in providing endoscopic services. General surgeons in rural areas frequently perform endoscopic procedures, averaging more than 200 cases per year, and endoscopy composes up to 40% of the procedures performed by rural surgeons.6

To provide effective endoscopic care, all surgeons must be knowledgeable and skilled at performing these procedures. Despite decades of experience, debate continues regarding training, assessment, and credentialing for endoscopy. The scientific evidence devoted to studying competence, proficiency, expertise, and assessment in endoscopic training suffers from small numbers and lack of statistical power. The largest study retrospectively examined 13,000 lower endoscopies performed by surgeons, and found that safety, skill, and efficiency were all achieved at a learning curve of 50 cases.7 However, these 50 “learning” cases must still be performed on actual patients, with the attendant risk of complications from endoscopy performed by novices and potential compromise of patient safety. The need to protect patient safety is now at the forefront in the training of future surgeons, and surgical education is therefore undergoing a paradigm shift. Part of this change, which can help overcome the disadvantages of traditional training, involves the use of simulation education and technology in endoscopy. It is with this in mind that the Society of American Gastrointestinal and Endoscopic Surgeons appointed a task force to create and validate a program that measures competence in the basic knowledge and skills to perform safe flexible endoscopy and to evaluate the program for validity evidence. This program is called the Fundamentals of Endoscopic Surgery (FES). This educational effort requires residency programs to have experienced endoscopists available, in addition to possibly providing dedicated clinical rotations for flexible endoscopy training. Additionally programs are expected to have flexible endoscopy simulators (computer based and inanimate or animate) available as part of their skills training laboratory, and a workable simulation curriculum that assess skills acquisition and proficiency. This review examines the current available literature on endoscopic simulation curricula and available modalities for endoscopic simulation.